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Indigenous Deaths in Custody: Part E Profiles: Indigenous Deaths in Custody 1989 - 1996

Part E Profiles: Indigenous Deaths in Custody 1989 - 1996

New South Wales



Western Australia

South Australia


Northern Territory

Other Deaths in Custody


South Australia

1SA 4/7/89 16


Police Ceduna Police Station Self-inflicted
9SA 4/11/89 30


Prison Yatala Labour Prison Natural
20SA 30/6/90 40


Prison Mobilong Prison Natural
29SA 1/8/91 39


Police Adelaide Injury
54SA 2/1/94 35


Police Salisbury North Gunshot
60SA 17/5/94 22


Prison Yatala Labour Prison Self-inflicted
68SA 27/1/95 18


Prison Yatala Labour Prison Self-inflicted
73SA 27/3/95 34


Prison Port Augusta Prison Self-inflicted
77SA 11/7/95 50


Prison Yatala Labour Prison Natural
78SA 15/7/95 29


Prison Adelaide Remand Centre Natural
82SA 28/7/95 22


Prison Yatala Labour Prison Self-inflicted
84SA 9/10/95 24


Prison Port Augusta Prison Self-inflicted


Male 17, died on 4 July 1989

Ceduna Police Station, South Australia

Self-inflicted Hanging

Coronial Inquiry Coroner Barry Ahern

Finding handed down 23 July 1990


The cause of death was hanging.

Summing Up

Circumstances of Death

The deceased was travelling with a friend in a car on Kloeden St, Ceduna at around 1:30am on the morning of Sunday 2 July. The car was approached by police who later stated that they were attending to a break-in in the street. The officers ran a warrant check on the pair. The friend was allowed to go but the deceased was arrested on warrants for non-payment of fines and a non-appearance on an assault police charge at Port Lincoln Courthouse, 300km from Ceduna. Following the arrest procedures the deceased was placed in the police cell complex around about 2.30am.

On Monday 3 July the deceased was unable to obtain any legal representation at a bail hearing before two justices of the peace. The deceased had spoken to the receptionist at the Ceduna Office of the Aboriginal Legal Rights Movement (ALRM) after the police prosecutor advised him that bail would be opposed. The solicitor was on leave and the case worker was unavailable. The receptionist attended the police station, but was unable to assist as she had no legal training whatsoever. The police prosecutor made the decision to oppose bail due to the deceased's non-appearance for an assault police charge and for not paying certain fines which would have apparently resulted in at least a four day sentence. Bail was denied by the Justices of the Peace and the deceased was remanded in custody. There were no records kept of the reasons for the decision to refuse bail.

A court hearing at Port Lincoln in relation to the assault police charge was set down for 11 July. Although police told the deceased he could make a fresh bail application if he was transferred to Port Lincoln, he received no response to his requests about arrangements for transport. Police air transport did not reply to a request, and the Ceduna police made no other attempts to arrange transport. The deceased was aware of the lack of arrangements.

Station reports show that the deceased received a meal about 1:30pm on 4 July. He was found by an officer escorting a witness to the cells about 3:30pm who saw the deceased hanging in cell by a pair of shoelaces which had been threaded through mesh in the ceiling, which had ironically been installed to prevent access to potential hanging points. No pulse or movement were detected and it was considered that the prisoner was dead. The local doctor was notified and declared the deceased to be dead.


The deceased at no stage received advice from a properly trained legal representative on the issue of his bail entitlement, nor was his application for bail considered by legal experts (unlike magistrates, justices of the peace do not possess legal qualifications).

The Coroner found that the deceased had not been checked for over two hours prior to being found hanging, and criticised procedures for the checking of prisoners. Counsel for both sides at the Inquest agreed that the investigation carried out into the death was fair and that there was no evidence to suggest foul play. The Coroner noted that an Aboriginal Visitors Scheme had been introduced in Ceduna, and improvements had been made to first aid training and procedures for cell checks in the past three years as a result of the Royal Commission.


1. The colour of the mesh which covers the bars made it difficult to have a clear view of the cells. The mesh should be repainted black.

2. The Coroner stressed the importance of continuing first aid training for all police officers. Attention should also be given to resuscitation methods and the use of the laerdal mask. It would be desirable ultimately for all police officers to hold certificates in first aid procedures.

3. All command circulars, general orders and other documentary material relating to the welfare and safety of prisoners should be contained in one folder. There is some evidence to suggest that some of the officers were not aware, or at least fully acquainted, with details of such documents located at the Ceduna Police Station. The Coroner sensed an attitude of laissez-faire in some witnesses.

4. The station journal should record accurately and faithfully all checks made on prisoners. As stated in this case, there is no evidence to indicate that the deceased was checked after 1.30pm on the Tuesday afternoon. If he was checked, then this fact is not recorded in the station journal as it should have been.

5. Staffing levels should be considered. Levels at Ceduna at present may be insufficient.

6. A psychological debriefing of the person who dies in custody should be available to the next of kin irrespective of the circumstances of death.

Royal Commission Recommendations Breached

R122c Police administrators to ensure that officers are aware of and trained to meet their responsibilities.

R123 Instructions on care of persons in custody to be known, understood, enforceable and publicly available.

R125 Screening form to be routine part of reception into custody and to be evaluated.

R126 Careful completion of screen form and risk assessment by a trained person to precede placement in a cell.

R133 Training of police officers to recognise those in distress or a risk. (IR28)

R137 Police training and instructions to require checks of detainees, specified intervals between checks on the health and safety of detainees.

R138 Persons detained should be closely monitored and observations made during cell checks should be recorded. (IR15)

R158 First priority on finding a person apparently dead to be resuscitation and medical assistance.

R160 Basic training for all police and prison officers in revival techniques.

Social Justice Commissioner


This death was doubly tragic. A friend of the deceased since childhood had lent the deceased his car the night of the arrest, and the transcript reveals that he also took his own life before the inquest.

The refusal of bail is a very important issue in this case (R89, R91). The Coroner declined to make a finding on the issue, saying 'I am certainly loathe to make any statement, particularly in the form of a recommendation, concerning the discretion vested in a police authority to arrest in such circumstances as prevailed here. The same comment applies to the discretion vested in a court to grant or withhold bail� Indeed it would be improper for me to lay down any guidelines.' This conflicts with the role that the Royal Commission recommended for the coroner (R12, 35). The Coroner pointed to a breach of 'a serious obligation to appear at the Port Lincoln Court' without ascertaining whether the offending behaviour at Port Lincoln was serious or trivial, or whether police had been justified in arresting the deceased, presumed innocent at law while on remand. The Coroner's praise of the police post-death investigation needs to be qualified in light of this omission.

Reasons given for the denial of bail were (a) the seriousness of the offences (Assault Police Sec 43 Criminal Law Consolidation Act is an indictable offence); (b) the lack of good explanation for the previous non-appearance in Port Lincoln; and (c) the fact that 4 days would have had to be served for the non-payment of fines.

Counsel for the Aboriginal Legal Rights Movement pointed out in relation to a) that there was no exploration of why the serious indictable charge had been laid rather than the complaint of assault police under the Summary Offences Act. In the case of the young man who died in the John Oxley Memorial Hospital (see A7QLD) the charge of seriously assaulting a police officer was laid (an indictable offence) because the mentally ill deceased had spat on a police officer. Recent cases also indicate this serious charge having been laid against Aboriginal people in circumstances of police provocation. 1 The circumstances of the assault police charge were not outlined by the Coroner, but, as chapter 6 shows, this charge is laid in trivial circumstances where a caution would suffice (R87). These issues were never tested in court, so the Coroner should have addressed the appropriateness of the arrest which led to the warrant for the serious offence being issued (R35c).

In relation to (b) the evidence indicates that the deceased had not appeared in Port Lincoln because he resided a long way away in Koonibba, near Ceduna. The deceased was advised that he could apply for bail again in Port Lincoln, but no arrangements were made for him to get there. The deceased wanted his matters transferred to Ceduna, which could have taken place only if he had entered a guilty plea. He was not aware of this. The criminal history sheet of the deceased disclosed no prior non-appearances and only a few juvenile appearances. Unless there is a history of flagrant and deliberate non-appearance, magistrates in Ceduna normally endorse warrants for Aboriginal people who fail to appear so that they remain eligible for bail when they are reapprehended. This was not the practice in Port Lincoln, and counsel for the ALRM criticised the inconsistency.

In regard to( c), section 65 of the Sentencing Act allows for applications for community service in lieu of custody for non-payment of fines, even after a non-payment warrant has been issued.

The Coroner addressed the inability of the deceased to obtain legal advice. The ALRM's Ceduna solicitor was apparently on leave in lieu of a considerable amount of weekend work. The field officer was unavailable. The Coroner implicitly criticised the fact that the solicitor did not organise a replacement for the Monday. This type of problem is more likely in an environment where a community legal service is overstretched with inadequate resources. The State and Commonwealth Governments must share responsibility given their funding role. However, the primary fault lay with the ALRM. It is totally unsatisfactory that the Ceduna Office had no protocols for referring applicants for bail, who are innocent until proven guilty, to another solicitor or legal service office in cases where the legal office is unmanned.

The Coroner recommended increased police staffing levels, although this seems to have been a misunderstanding. The submission from the Police Service, supported by counsel for the ALRM, was that ALRM staffing levels should be increased. The ALRM also pointed out that the deceased would not have been able to obtain their assistance at Port Lincoln when he was charged with assault police, as submissions for funding for a Port Lincoln ALRM office had never been approved.

The Coroner's recommendation about repainting the mesh which was used as a hanging point seems not to go far enough. The mesh was obviously unfit for its purpose, which was to prevent hangings. Conditions at the Ceduna cells were poor - it was the middle of winter, the cells were spartan, cold and lacking in adequate exercise space (R148). New cells were in construction by the time the Coroner made his findings. Submissions from the Aboriginal Legal Rights Movement indicated that flexible custody arrangements recommended by the Royal Commission had been discontinued at Ceduna (R149).

The case reveals the danger implicit in using Justices of the Peace to make bail decisions (R98). The lack of legal expertise on the bench for the unrepresented accused possibly denied him the right to apply for a community service order for his unpaid fines, a right which implements the principle of imprisonment as a last resort (R92).

Additional Royal Commission Recommendations Breached

R12 Legal requirement for Coroner to consider how the person was treated before death.

R35 Investigators to examine circumstances of arrest and treatment in custody. (IR55)

R87a Police to apply the principle of arrest as a last resort. (IR8)

R87b Police administrators to train and instruct to ensure the principle of arrest as a last resort is applied.

R87c Administrators to take a more active role in reducing unnecessary custodies.

R87d Governments consider formal cautions for certain offences.

R89 That entitlement to bail is recognised in practice.

R91 Consideration of amending bail legislation to enable review of police denial of bail, revision of inappropriate restrictions on granting bail to Aboriginal people and to allow release of an arrested person without passing through a police station. (IR10)

R98 Phasing out of the use of justices of the peace for determination of charges and sentencing.

R108 Sufficient funding for Aboriginal Legal Services to represent clients.

R121 Where not already in place, legislation that imprisonment not be automatically imposed for default on fine payments, alternative sanctions legislation, and statutory duty to consider capacity to pay.

R148 Cell refurbishment, replacement of dilapidated cells, but not in place of implementing the other custodial health and safety recommendations.

R149 That Police Services should recognise the need for flexible custody arrangements which allow greater freedoms to Aboriginal detainees.

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Male 30, died on 4 November 1989

Modbury Hospital (ex Yatala Labour Prison), SA

Natural Causes, Terminal illness

Coronial Inquiry Coroner Kevin Ahern

Finding handed down 28 June 1990


The cause of death was terminal haemorrhagic bronchopneumonia and pericarditis complicating diffused uncontrolled chronic myeloid leukaemia.

Summing up

Circumstances of Death

The deceased had been diagnosed with terminal cancer in 1980 during a term of imprisonment. He was on remand in Yalata Labour Prison when he was transferred, at his own request, to hospital. The Coroner noted a very severe exacerbation of his acute leukaemia. He was in a lot of pain, and needed constant narcotic analgesia for relief.

The deceased died of illnesses associated with his advanced terminal cancer some five days after he arrived in the hospital.


The Coroner found that the deceased had a substantial history of self-mutilation such as swallowing of objects such as spoons, razor blades, wire and wire clips etc. Psychiatric reports described the deceased as suffering from a disturbed personality, and who manipulated staff to an extreme degree.

Postponement of sentencing caused the deceased to protest by 'slashing up' - cutting his arm with a razor blade. As a result, sentencing occurred at the deceased's bedside on the day prior to his death. The Coroner had no doubt that the length of the actual sentence (five years) upset the deceased greatly.

The Coroner considered that the deceased was treated humanely by prison, medical and hospital staff, particularly in the latter days of his life. The submission from Counsel for the next of kin acknowledged that the deceased had been treated humanely in the latter days of his life. The Coroner and Counsel for the next of kin also commended the manner in which the investigation was carried out and the detailed report prepared.

Recommendations Nil

Royal Commission Recommendations Nil

Social Justice Commissioner


The deceased had a terminal disease, and was going to die regardless of the treatment he received. The Coroner was operating under legislation which allowed him only to make findings and recommendations to prevent similar further deaths. 2 He therefore had no jurisdiction to consider submissions from the next of kin regarding verbal abuse and victimisation of the deceased by some prison officers.

Ignoring allegations of poor treatment, however, is not in the public interest in accountability. While no blame at all can be attributed to the Coroner for not considering the treatment of the deceased before his death, blame does attach to the State Government, which has claimed full implementation of Recommendation 12, calling for treatment prior to death to be investigated. The Government no longer reports on Recommendation 12. It does report on Recommendations 13 and 18, which demand a wider power for the State Coroner to investigate, but only to state that the current powers are adequate. Royal Commission Recommendation 182 requires the instruction of Corrective Services Officers for courteous interaction with prisoners, and any deliberate breach to be a disciplinary matter. Evidence of poor treatment could not be referred to the relevant authority for investigation. In Victoria, the State Coroner has statutory powers to investigate the treatment received by a prisoner prior to death, and to make findings and recommendations to remedy any problems revealed. 3

The Coroner did note that it was unfortunate that the deceased's personal file was destroyed by Correctional Services prior to the inquest. The Coroner made no recommendations.

Additional Royal Commission Recommendations Breached

R12 Legal requirement for Coroner to consider how the person was treated before death. (IR46)

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Male 40, died on 30 June 1990

Modbury Hospital, ex Mobilong Prison, SA

Natural Causes, Heart disease

Coronial Inquiry Coroner L K Gordon

Finding handed down 3 May 1991


The immediate cause of death was pulmonary oedema, which was due to acute mitral incompetence, which was due to rupture of the papillary muscle, which was due to a coronary occlusion due to coronary atheroma. There was no evidence of unnatural or recent trauma.

Summing up

Circumstances of Death

The deceased was imprisoned at Mobilong Prison for three months for offences against justice procedures.

The deceased had complained of abdominal pain and discomfort for some days prior to his death. The earliest record or any incident was a reference to chest pains on and off lasting 1-2 hours on 1 May 1990. On 22 June he was admitted to Modbury Hospital and treated for a gastric upset and was discharged two days later.

On 28 June, the deceased again presented to the surgery complaining of headaches, a cold, the flu and abdominal pain. The medical practitioner, after being informed of the diagnosis of gastric upset at the hospital, advised the prison nurse to treat the symptoms as they appeared. The deceased told the nurse that he still had diarrhoea he and complained of stomach discomfort. He was treated for gastric problems.

The deceased played a game of football in the early afternoon. After the game he complained of being unfit and having no wind. The deceased at about 4.14pm stated to a prison officer on the intercom that he was coughing up blood. At 5.41pm the deceased advised that he was still coughing up blood and the prison officer saw visited the cell and saw two large patches of bright red frothy blood. After coughing up yet more blood at 5.20pm, the officer decided the deceased was quite ill. His temperature was 38.3c, his pulse was 140 and he was having difficulty breathing.

Arrangements were then made to transfer the deceased to the clinic at Murray Bridge. After some forty minutes while an escort was arranged, and a further wait of 15-20 minutes at the clinic, a doctor, having the prison medical records, considered the deceased did not appear to be severely ill. He diagnosed right basal pneumonia.

Confusion followed over where to send the deceased. The doctor considered the Yalata prison infirmary could provide an appropriate level of care. The deceased was transported to Yalata Labour prison in the cage of the van in which he had been transported from Mobilong and arrived at 8.10pm. His condition had deteriorated and there was a further delay while prison medical staff confirmed arrangements made by the doctor.

It was decided to transfer the deceased to hospital which necessitated escorts being arranged by call-back of off-duty Correctional Officers. The nurse on duty did not consider the condition to be life-threatening and did not interpret the prison doctor's instructions as urgent or requiring the immediate attendance of an ambulance. Subsequently the deceased did not arrive at the hospital until 10.30am and was not seen by a doctor until 11.30pm. The deceased's prison medical record did not accompany him to the hospital. Again an incorrect diagnoses did not take the possibility of heart disease into account and the deceased was treated for pneumonia.

At around 4.45am, the deceased suddenly arrested and respiratory and external cardiac resuscitation and medication were administered. When there was no spontaneous respiration, arrangements were made to transfer the deceased to the Royal Adelaide Hospital, as both ventilators were in use. He was certified to be dead on arrival at 7.35pm on 30 June 1990.


The deceased had a serious alcohol problem from about the age of 18 years. He had treatment on a few occasions and was advised that if he did not do something about his alcohol problem, it was likely he would die from it.

The Coroner found that a number of factors contributed to the death, the cumulative effect of which disclose delay and failure to accord the deceased's health and welfare the care and attention to be expected. He stated that 'this inquiry has produced a saga of unnecessary delays, confusions and diagnostic errors.' He found an absence of adequate and prompt attention to routine procedures which the needs of an accelerating deterioration called for. Allowing for excusable delays he found that the deceased was without proper medical care for three to five hours, and that this was a contributing factor to the death.

That there were only two ventilators at Modbury hospital (both were in use). This was also found to be unsatisfactory.


The Coroner commented that recommendations were made against the background that prison personnel have a legal duty to care for prisoners in custody, extending to medical care.

1) The provision of Correctional Services' staff to escort prisoners to hospital or other medical services.

a) Certainty of guidelines and authoritative directions, especially in urgent cases to transfer prisoners to hospital or other medical services are essential.

b) Where a medical practitioner, or nurse decides that a prisoner requires hospital treatment or some other medical services not available within prison, an escort be provided in compliance with the degree of urgency of the case.

c) Guidelines to determine degrees or urgency should be formulated.

d) A request for an escort should be acted upon immediately in accordance with the degree of urgency determined by the medical practitioner. Whether or not extraordinary measures will have to be taken (eg temporarily closing down a prison or part, or transfer of officers from other duties) should depend upon the degree of urgency.

e) In cases of extreme urgency, any officer, aware of the circumstances, should have the authority to determine the degree of urgency and give directions accordingly.

2) Information about medical services available to prisoners

a) A comprehensive information handbook should be compiled in conjunction with the SA Health Commission setting out the diagnostic, treatment and other medical facilities which may be made available to prisoners.

b) This document should clearly set out the facilities available to prisoners and any procedures to be observed to obtain admission or access to a particular service. Any such conditions or procedures should be made as simple as possible.

c) The information should be provided as a matter of course to all prison medical staff and medical practitioners outside the Correctional Services Department, who are likely to be called upon to a sick or injured prisoner.

d) The information should be updated as required.

3) The need for a prisoner's medical records to be available

If it is not normal procedure for a prisoner's medical records to accompany him or her upon transfer to any other prison or hospital, it is essential that steps be taken to ensure that this is done.

Royal Commission Recommendations Breached

R150 Standard and range of health care of persons in correctional institutions to be the same as for the general public; adequate resources and 24 hour access to be available.

R152a Review of health services provided to Aboriginal detainees with Aboriginal Medical Service and other bodies to consider standard of health services available.

R152e Information exchange between prison and other medical services.

R152f Review of health services to include exchange of information between prisons and medical services/practitioners.

R154a Training of Prison Medical Services staff to ensure they understand Aboriginal health issues. (IR28)

R161 Instructions to seek immediate medical care if doubt on prisoner's condition. (IR40)

Social Justice Commissioner


As the Coroner indicated, the failure to diagnose a heart attack in the prison and the hospital, the delays in obtaining medical care, the miscommunication of medical information and the fact that both ventilators at Modbury Hospital were being used, all combined to produce a tragically poor standard of medical care. The stress caused to the deceased may have exacerbated the underlying heart disease.

The deceased was placed in a side ward on his own in Modbury hospital, tied to the bed with a leg restraint. This practice may appropriately address a need for security in some cases, but seems excessive in light of the deteriorating condition of the accused in this case. The policy of calling in off-duty officers 'from outside' to accompany an ambulance was also inappropriate. Calling for an ambulance in the first place would suggest that urgency was required.

Additional Royal Commission Recommendations Breached

R156 A thorough medical assessment done upon initial reception at a prison by a medical practitioner or a trained nurse, then assessment by a medical practitioner within 72 hours.

R247 More/improved training of non-Aboriginal health professionals in Aboriginal culture and society and life threatening conditions which are experienced by Aboriginal people.

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Male 39, died on 1 August 1991

Adelaide, South Australia

Heart Attack

Coronial Inquiry Coroner Kevin Ahern

Finding handed down on 19 May 1992


The cause of death, established by two post mortems, one conducted by a doctor appointed by the Aboriginal Legal Rights Movement (ALRM), was cerberal hypoxic damage (or 'cerebral anoxia') caused by or following a cardiac arrest. It was conceded that the incident with police may have been a trigger.

Summing Up

Circumstances of Death

The police were called to a house by a woman after the deceased walked unsteadily to her house, 'picked up the mat from the front door and put it on his back and laid out across the verandah.' She also called her son and a male friend, who were present in the house when the police arrived.

The deceased had left the premises when police arrived and refused to answer when police told him they wished to speak with him. The police officer then apparently walked [dragged] the deceased in a backwards direction when the deceased lashed out with his legs. Another police vehicle arrived on the scene and intervened to assist the first officer. One artificial leg fell off. Following a violent struggle with police officers and the deceased wrestling on the ground in a struggle lasting some fifteen minutes, the deceased was finally subdued and handcuffed.

The police finally took the deceased into custody for offensive language, assault police and resist arrest. Shortly after being pinned down to the ground he was noted to be unresponsive and pulseless. CPR was administered by police and ambulance officers who transported the deceased to Modbury Hospital. He was taken to the Royal Adelaide Hospital intensive care unit with signs of hypoxic brain damage and failed to regain consciousness.


The deceased was described as itinerant and nomadic spending the major part of his life in parklands' and drinking alcohol heavily. He had lost his right leg below the knee and left leg below the ankle. Police were called by a woman who had seen the deceased standing on her property and walking unsteadily and assumed that he had been drinking.

The post-mortem report further noted that the deceased had a history of alcohol abuse, alcohol related brain damage and epilepsy and this would have predisposed the deceased to the heart failure. There was some indication from police statements that there had been pressure applied to the upper torso while the deceased was lying face down on the ground.

A substantial number of witnesses were called to give evidence at the Inquest. The Coroner found that there were serious discrepancies in the evidence given by the son of the house owner and his companion.


It is encumbent on all police as far as possible to carefully weigh the facts and the circumstances before exercising the prerogative of arresting a person at a particular scene.

Royal Commission Recommendations

R87 Police to apply arrest as a final sanction, and implement practical procedures to ensure this occurs.

Social Justice Commissioner


Pathology tests showed a blood alcohol level of nil, although most of the witnesses assumed that the deceased was drunk. His serious and chronic medical problems were not taken into account by police. He had a number of previous convictions for such petty matters as walking on roadway, drunk on railway, a number of assault police, offensive language, urinating in public and insufficient means (vagrancy) and was well known to police.

Coroner considered that deceased standing in the front lawn meant something was amiss, even though he had moved away from the house and was apparently going on his way. The deceased had artificial legs, and walking (dragging) him backwards, would have caused discomfort.

The apparent sensitivity of police towards offensive language has no credibility as a reason for initiating arrest, as a case recently heard in the NSW Court of Appeal indicated. 4

Additional Royal Commission Recommendations Breached

R60 Elimination of, and disciplining for, rough police treatment, verbal abuse of Aboriginal persons and use of racist or offensive language.

R86a Offensive language during police initiated action not to be basis for arrest and charge.

R163 Regular training of police and prison officers in restraint techniques.

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Male 35, died on 2 January 1994

Salisbury North, Adelaide, SA

Police shooting

Coronial Inquiry Coroner Kelvyn Prescott

Finding handed down 23 June 1995


Death was the direct result of being shot by police officer on 17 December 1993. It was also found that the actions of the deceased led to his death.

Summing up

Circumstances of Death

The deceased was intoxicated. He had been involved in a fight with another intoxicated person who called the police. As a result of the caller's intoxication it took some minutes for the police operator to discover his address. The Coroner found that a second caller did not mention that the deceased had a knife, although the tape of this call had been wiped. Police were therefore not prepared for the situation that developed. Statements from witness indicated that the deceased had threatened to kill a number of people.

One police officer tried to detain the deceased by grabbing him through a car window after he had dropped the kitchen knife he was carrying. She was unsuccessful. The police car drove off, did a U turn and stopped. The police left the car and drew their guns. The deceased was warned repeatedly to put down his knife. Witnesses reported that he challenged the police to shoot him. He was found to have been shot at close range while lunging at one of the officers.

Following the shooting, the deceased was immediately attended by ambulance and was taken to intensive care. He ultimately died of wounds associated with rupture of the bowel and onset of faecal peritonitis.


The deceased was described by the Coroner as an invalid pensioner, deeply depressed and possibly suffering from a schizoid personality induced by alcohol abuse. His father died when he was very young and he witnessed the death of his mother. His relationship with his adopted family was poor. He had no employment history and minor contact with police over a number of years.

The Coroner found that there was little the police could do to diffuse the situation given the poor visibility, the danger to the public, and the actions of the deceased.

At one point the deceased had dropped his knife. Counsel for the family claimed it was apparent by the dropping of the knife that the deceased may well have calmed down. He claimed that attempting to grasp the deceased had the potential to imflame the situation, and was a provocative and a premature thing to do. He argued that a policy of calm appeasement was required at this time, and that an attempt at dialogue with the deceased, keeping a safe distance, would have been appropriate.

The Coroner found that criticisms of the actions of the officer, who had to make difficult operational decisions in a difficult situation, as triggering the response by the deceased were not appropriate. However, he noted that the officer in the passenger's seat of the police car was not in an optimal position to take hold of the deceased, who was standing in the street, and he made a relevant recommendation.

The Coroner found that the police officer who fired the fatal shot acted reasonably, given the behaviour of the deceased in lunging towards him with the knife.


1. That the call line identification facility be provided to the police for all calls made to it on the 11444 number, allowing police to identify the address of the caller immediately;

2. That protocol be established for preservation of tape-recordings of calls to incidents which are designated major crime; and

3. That the premature action of the police officer in attempting to detain the deceased when she was disadvantaged needs to be examined by those involved in the training of officers.

On the evidence of the Police Training Officer the Coroner found that it was not the practice that warning shots be fired first. On the submission from the family's representative, he expressed an opinion (while not making a recommendation concerning Police General Orders) that the practice of not firing a warning shot be revisited. He noted that the recommendation not to use warning shots was made by the Mitchell Committee in 1974, and that since then alternatives such as capsicum spray had been developed and all operational police had been issued with firearms. The Coroner considered it desirable that alternatives such as capsicum spray be used by police in such situations so that offenders are debilitated rather than killed.

Royal Commission Recommendations Breached

R162 Consideration of laws/instructions on use of firearms in arrest or preventing escape.

R163 Regular training of police and prison officers in restraint techniques.

Social Justice Commissioner


While acknowledging the difficulties facing police, the pattern of fatal police shootings of mentally ill persons is disturbing. Police training should emphasise mediation / negotiation / management techniques where possible to calm rather than inflame aggressive situations.

The Coroner's findings described the events immediately surrounding the shooting. They contained no detail of the attempted detention of the deceased when he had dropped the knife, although a brief finding and a recommendation were made about the incident.

Additional Royal Commission Recommendations Breached

R215 Police to introduce procedures for local negotiation on police methods and perceived problems.

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Male 22, died on 17 May 1994

Yatala Labour Prison, South Australia

Self-inflicted Hanging

Coronial Inquiry State Coroner Wayne Chivell at Adelaide Coroner's Court

Finding handed down 24 May 1995


The cause of death was neck compression due to hanging and the deceased died by his own act. There were no injuries or other signs that any other person was involved in the deceased's death.

Summing Up

Circumstances of Death

At 4.30pm on the day of his death, the deceased was locked in his cell in B Division of Yalata Labour Prison. At approximately 9:12pm during a routine head count of prisoners, the deceased was noticed hanging by a belt suspended from an overhead water-pipe.

Within a minute or so, the cell door was opened and the body was taken down. Prison officers commenced cardiopulmonary resuscitation, manually at first then with the aid of Air-Viva equipment. Nursing staff also attended until the ambulance arrived and found no signs of life.

The doctor confirmed the deceased was dead at around 9.40pm. The forensic pathologist, attended at about 10.30pm and determined that the time of death was between 5.30pm and 6.00pm that evening.


The Coroner noted that the deceased had first appeared in the Children's Court at the age of fifteen years, with regular appearances after that time until March 1992, when he sentenced to a total of forty-five months for various charges of dishonesty. By the age of seventeen the deceased had developed a serious dependency on heroin, and from there on his offending was mainly drug related. He had also developed Hepatitis C by the time of his last imprisonment. He was on parole from May 1993. The incident for which he was charged this time occurred whilst on parole. The deceased's de facto wife was superficially wounded in the head as a result of discharge of a firearm.

The Coroner found that when the deceased had been remanded in Adelaide Remand Centre, before his transfer to Yatala, he had been seen by the prison nurse and a medical practitioner. He was assessed on admission as 'at risk,' although he denied any suicidal thoughts. He had declined to attend a review of his mental state at the nurses clinic on 4 December and no further action was taken in relation to the deceased's mental state from that time onwards.

A number of factors were found to have contributed to the decision by the deceased to end his life, including:

Imprisonment - the conditions of imprisonment which included staff cut backs meaning that there were no educational, vocational or employment training programmes; early lock-downs and separation from his pregnant de facto wife and son;

Outstanding charges - likelihood of extensions to his term of incarceration for breaking parole conditions;

Prison stresses - where the deceased 'was concerned that there was a rumour he was an informer' ('a dog') and he feared for his safety. The Coroner found that 'he had become obsessed with the issue� calling out at night and having imaginary conversations with his accusors'.

Relationships - the deceased's relationship with his previous de facto wife to whom was addressed a suicide note, was found to be 'remarkable for its abusiveness and bitterness';

Mental Illness - the psychologist considered there was no history of psychosis. However the Coroner expressed an opinion that the drug taking by the deceased may have had the effect of 'unmasking any mental illness'.

According to his probation officer and other witnesses he was also unable to control his anger and was generally an angry and impulsive young man. The Coroner considered it likely that all or any of the abovementioned factors suddenly caused him to turn his anger inwards resulting in an impulsive decision to commit suicide.

The lack of a standard requirement for periodic observations of prisoners in B Division at the time of his death meant that it was only during the 'swing shift' process, when the guards change shift, that the deceased was found. The Coroner found that it was possible that a prisoner who has been locked in his cell early may not be checked [until] 12.10am the next morning.


1. That the Department for Correctional Services (DCS) review its Standard Operating Procedures in relation to prisoners who may be 'locked down' for the evening with a view to instigating a regime of observation of such prisoners on at least an hourly basis until such time as the prisoner appears to be asleep.

2. That DCS improve its system of record-keeping in relation to prisoners' dossiers and verify the accuracy of the information in its dossier with the prisoner concerned. This is particularly the case in relation to the racial background of the prisoner and its relevance to the procedures recommended by the Royal Commission into Aboriginal Deaths in Custody.

3. That DCS urgently reconsider its policy of reliance on detection of 'at-risk' prisoners and instigate refurbishment of the cells in 'B Division' so that hanging points are minimised to the greatest extent possible consistent with the safety, dignity and comfort of the prisoner. (See later case profiles where this was still not done.)

4. That D.C.S. continue to emphasise the importance of record-keeping in relation to incidents within the prison, both by training and, in cases of deliberate or negligent failure by the exercise of appropriate disciplinary measures. This recommendation applies both to the keeping of logs as the incident occurs, and to the filing of incident reports required after the incident.

Royal Commission Recommendations Breached

R152g(ii) Protocols for care and management of Aboriginal prisoners who have drug related conditions.

R152g(v) Protocols for care and management of Aboriginal prisoners who angry, aggressive or disturbed.

R152g(vi) Protocols for care and management of Aboriginal prisoners who suffer from mental illness.

R156 Thorough medical assessment on reception.

R165 Elimination/reduction of items with potential for self-harm.

R184 Authorities to ensure that all Aboriginal prisoners have the opportunity to perform meaningful work and to undertake education courses.

Social Justice Commissioner


The Coroner found a considerable body of evidence before him that in the several weeks prior to his death the deceased was displaying clear signs of mental disturbance. The calling out and conversations with what the deceased believed was the devil became so regular that it was treated as a joke by other prisoners. Prison staff denied witnessing this behaviour. Two inmates said that they had seen officers walk past the deceased's cell when he was calling out, and that they drew the deceased's condition to the attention of prison officers. Both witnesses were disbelieved, their evidence inconsistent with Aboriginal prisoners who gave evidence.

There was evidence that prisoners took active steps to conceal symptoms from custodial authorities in case it resulted in a transfer of the deceased to an observation facility, which prisoners regard as a punishment and physically unpleasant. Apparently, prisoners' friends often conceal their concerns from officers because they might be seen as 'dogs' if they inform staff.

The code of silence amongst prisoners is an issue in this case, as it prevented the condition from being noted and action taken. However, the action which could have been taken is unclear given the resources at the prison - special facilities for behaviourally disturbed do not exist at Yatala. Certainly, observation cells should not be used for punishment, and conditions in observation cells should be improved so that prisoners do not see the need to avoid them at all costs.

As the deceased's 'Aboriginality' was not noted by the prison authorities, no special procedures as set down by the Royal Commission were followed. It is conceivable that had an Aboriginal Welfare Officer been employed as in Royal Commission Recommendation 174, this problem may have been overcome. The deceased's Aboriginality was known to other inmates, including his uncle.

Additional Royal Commission Recommendations Breached

R152d Appropriate facilities for behaviourally disturbed.

R174 Employment and location of Aboriginal Welfare Officer by Corrective Services.

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Male 18, died on 27 January 1995

Yatala Labour Prison, South Australia

Self-inflicted Hanging

Coronial Inquiry State Coroner Wayne Chivell

Inquest not completed

Social Justice Commissioner

Circumstances of death 5

The deceased was found hanging at approximately 10:15pm after being locked alone in his cell on the second floor of the prison. He had not been checked for some six hours, since being locked in at 4:30pm. Prison officers and a nurse were unable to resuscitate the deceased.


The deceased was serving a nine month sentence imposed by a Childrens' Court for offences committed as a juvenile. The day he died the deceased had attended a meeting conducted by the Aboriginal Legal Rights Movement where deaths in custody was discussed. He was described by witnesses as 'distressed, agitated and frightened' because he did not think he should be in B Division, the maximum security section, where he was treated as a sentenced prisoner and locked up at night alone. He was overhead telling another inmate (his cousin) that he could 'do it' in the fifteen minute interval between cell checks. However, staff stated that they had no indication that the deceased was suicidal and he was not placed in an observation facility.

Hanging points (exposed plumbing pipes in the ceiling) remained despite previous recommendations that they be removed or covered. Prison officials advised that this was because of costs, and the problem of making the cells even more claustrophobic with a false ceiling. Following two similar hangings however, work was reportedly underway to cover the pipes in cells which would be used for emergency accommodation for 'at risk' prisoners.

The deceased's bail conditions had been altered and met four days before his death and he should have already been transferred to a juvenile facility, the Cavan Training Centre. The Correctional Services Clerk told the Inquest that she had not seen the bail papers before, so no action or arrangements had been made.


This death raised critical questions about organisational flaws within the prison system. For instance why was a juvenile on remand locked up alone in a maximum security cell as a sentenced prisoner? Why was a remand prisoner incarcerated with sentenced prisoners? Why was a bailed prisoner still locked up?

The locking up of juveniles in adult prisons and the failure to separate remand and sentenced prisoners is contrary to the International Conventions on Civil and Political Rights, unless special circumstances exist which mean that the best interests of the juvenile are served by these measures. Preliminary evidence before the Coroner indicates that the deceased was placed in the particular high security adult wing because it enabled more out-of-cell time, and enabled him to be in contact with Aboriginal relatives who were in the same wing. Correctional staff gave evidence that Aboriginal prisoners get preference in relation to requests for transfers within divisions of the prison for this reason. The crucial investigation that needs to be made was whether a proper procedure for considering the request for transfer was made, as outlined in chapter 9 of this report. It certainly should not be the case that prisoners with lower classifications face conditions which encourage them to seek transfers to higher security sections of the prison.

Although the Coronial Inquiry is not complete, indications are that a series of oversights and systemic failures contributed to the death. The deceased was young and recently incarcerated. An Aboriginal Welfare Officer was employed by Yatala Labour Prison, and was given information concerning certain 'at risk' behaviour which would have alerted custodial authorities to his suicidal ideation. This information was not passed on to custodial authorities. Again, the authorities failed to cover the pipes despite a number of earlier hangings. The solicitor had asked why he was in Yalata when the deceased's sentence was from the juvenile court, putting the prison on notice. The bail papers with favourable orders were lost.

Two-hourly checks of prisoners have been instituted since the death.

Additional Royal Commission Recommendations Breached

R95 Where motor vehicle offences are a major factor in imprisonment, programs to be consultatively developed to reduce incidence.

R152g(iv) Protocols for care and management of Aboriginal prisoners at risk of self-harm.

R152g(v) Protocols for care and management of Aboriginal prisoners who are angry.

R165 Elimination/reduction of items with potential for self-harm.

R167 Juvenile Detention Centres be reviewed to ensure compliance with custodial health and safety recommendations.

R181 Undesirable that an Aboriginal prisoner be placed in isolated detention.

R242 Aboriginal juveniles to be allowed bail wherever possible; laws and processes to avoid detention in watch-houses.

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Male 30, died on 27 March 1995

Pt Augusta Prison, SA

Self-inflicted Hanging

Coronial Inquiry Inquest not completed 6

Social Justice Commissioner

Circumstances of Death 7

The deceased had been transferred from a mental health institution to the prison ten days prior to his death. He had refused to take his anti-depressant medication and no action was taken to ensure that he did. He was found hanged in his cell with a belt attached to a hole in the mesh above the cell door.


The deceased had a well documented and well known history of mental illness, reported suicidal ideation and actual attempts. He had been committed to a mental health institution. The Prison Medical Service were aware of the deceased's history of mental illness, but they were not adequately advised by the Mental Health Service of the subtleties of the deceased's highly complex mental condition. The deceased was placed in a cell on his own. Prisoners who gave evidence at the inquest indicated that other prisoners were willing to share a cell with the deceased. There was also evidence that on several occasions prisoners declined to share a cell with the deceased.

A belt, a commonly used instrument for hanging, was left in the deceased's possession. He was found hanged in his cell with the belt attached to a hole in the mesh above the cell door. Prison officers did not hear the noise made when that the deceased had knocked a hole, large enough to thread the belt through, through the steel mesh door. The noise was heard by several other Aboriginal prisoners, and the deceased told one of those prisoners the next day that he had made the hole in order to hang himself. Unfortunately the prisoner failed to pass this information on.

Additional Royal Commission Recommendations Breached

R151 Referral of Aboriginal prisoners/detainees for psychiatric care.

R152a Review of health services provided to Aboriginal detainees with AMS and other bodies to consider standard of health services available.

R152e Information exchange between prison and other medical services

R152f Guidelines for exchange of information between medical and prison services.

R152g(iv) Protocols for care and management of Aboriginal prisoners who are at risk of self-harm.

R152g(vi) Protocols for care and management of Aboriginal prisoners who suffer from mental illness.

R152g(viii) Protocols for care and management of Aboriginal prisoners who are require medication.

R165 Elimination/reduction of items with potential for self-harm

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Male 50, died on 11 July 1995

Yatala Labour Prison, SA

Heart Attack

Coronial Inquiry Inquest not commenced

Social Justice Commissioner 8

Circumstances of Deaths

The deceased died from a heart attack in Yalata labour prison. Another Aboriginal inmate stated that he was with the deceased when he came out of the toilet, complaining of indigestion. Cell guards were called but by the time they arrived, the deceased had collapsed. At 2.05pm the deceased was taken to the infirmary and seen by a doctor at 2.15pm. However, at approximately 2.25 pm, the deceased suffered a seizure and was declared dead 2.45 pm.

No other information is available at this time.

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Male 29, died on 13 July 1995

Adelaide Remand Centre, SA

Heart Attack

Coronial Inquiry Coroner Wayne Chivell at Adelaide

Finding handed down 17 June 1996


The death was a result of ischaemic heart disease die to occlusion of the left anterior descending coronary artery by thrombus adjacent to a calcified atheromatous plaque.

Summing Up

Circumstances of Death

On the morning of his death the deceased had been released from his cell for 'cleaning and exercise' at around 7.40am. He refused his medication (sulprin). He made a phone call to a cousin around 8.00am. He made no mention of chest pains or feeling ill during the telephone conversation.

At around 8.55am, the deceased knocked on his cell door and advised the guard who responded that he had 'got pains in my chest'. The deceased was taken to the infirmary at around 9.00am and presented with severe pain. The nursing staff at the infirmary found 'no significant differences with previous ECGs' and the deceased was taken back to his cell.

About forty minutes later, the deceased complained that the pains were getting worse and he was again taken to the infirmary. The increase in his blood pressure was seen as significant and it was decided after a call to the doctor to place the deceased under observation in one of the wards. The deceased asked to see the nursing sister and when she returned, he 'had collapsed and vomited'.

An ambulance was dispatched with a Priority 1, arriving at 10.30am. In the meantime, nursing staff had commenced CPR, which included one nurse performing mouth-to-mouth resuscitation without protection when she could not locate a mask quickly enough.

The ambulance officers noted that the ECG indicated that [the deceased] was in ventricular fibrillation and three separate attempts at defibrillation were unsuccessful. Life was declared extinct at 11.05am.


The deceased had been treated by the Prison Medical Service on many previous occasions with the first recorded treatment [on] 15 May 1984. As early as August 1986, there was complaint of chest pain when the deceased was only 20 years old.

In March 1992, the deceased was admitted to Modbury Hospital from Yalata Labour Prison suffering from chest and neck paid radiating to his jaw and both arms. The diagnosis on this occasion was 'a no Q wave myocardial infarction' and the deceased was urged to give up cigarette smoking. The diagnosis was not entered on the deceased's file under the 'Problem List' which would have provided an easy reference for medical staff later. Nor was a later visit in August where the deceased was treated for angina mentioned on the Problem List.

The deceased was arrested on 10 April and admitted to the Adelaide Remand Centre on 13 April to await trial for sex offences. His heart condition was not mentioned on the admission record and the Coroner 'found it surprising' that the staff failed to 'notice how voluminous the casenotes were' and 'accepted the blank Problem List at face value'. Nursing staff considered that the lack of notice on the List meant there was no chronic condition.

The Coroner noted that specialists would have been able to determine abnormalities in the deceased's ECGs, and did not criticise prison medical staff who were not specialists. He did however 'find it disturbing' that medical staff did not ask the deceased 'about the history of his condition' nor consult the casenotes. He was also critical of the actions of the medical practitioner who was called for advice and who did not adequately enquire as to the symptoms presented by the deceased.

The Coroner considered that 'putting aside the actions of individuals involved � had the Prison Medical Service as an organisation operated effectively �, [the deceased's] chances of survival would have been much greater.'


1. That the Prison Medical Services discuss arrangements with a teaching hospital whereby, in cases where no doctor is quickly available, ECG readouts could be sent by facsimile with other relevant information, so that the material could be considered by an appropriately qualified specialist;

2. That the Prison Medical Service develop a series of clear protocols to assist both medical and nursing staff to take appropriate action in urgent situations;

3. That the Prison Medical Service review its systems in relation to record-keeping so that casenotes are kept up-to-date and reviewed for that purpose at appropriate intervals;

4. That the Prison Medical Service consider ways in which its records might be computerised;

5. That the Prison Medical Service consider the need for training and provision of information to medical and nursing staff in relation to the particular susceptibility of Aboriginal people to heart disease in particular and to other disease as well.

Royal Commission Recommendations Breached

R152e Information exchange between prison and other medical services

R152g (iii) Protocols for care and management of Aboriginal prisoners who suffer illnesses.

R154 Prison medical services staff to be trained in Aboriginal history, culture and lifestyle. Consultation with AHS on informing and training medical staff.

R157 Securing of comprehensive medical history from outside. To accompany prisoner on transfers.

Social Justice Commissioner


The Coroner made a number of valuable observations and recommendations. Given the large number of transfers between institutions, the use of computerised records of prisoners' health and mental state is becoming a minimum requirement to satisfy the custodial duty of care. In light of the geographical isolation of many prisons the use of facsimile machines to assist diagnosis in cases such as this is to be encouraged.

The use of procedures or guidelines such as the Problem List to streamline diagnosis and treatment for prisoners can have a detrimental effect if records are poorly kept. The 'voluminous casenotes' on the deceased's heart disease and the comments about the lack of regard for those notes illustrates this problem. Recruitment of additional qualified personnel and 'trained ancillary staff may be necessary. The Coroner conducted his inquiry into this death ably and responsibly.

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Male 22, died on 28 July 1995

Yatala Labour Prison, SA


Coronial Inquiry Inquest not commenced

Social Justice Commissioner

Comment 9

The deceased was 'serving a four month sentence for an assault charge.' Two days before his death, an Aboriginal Liaison Officer had contacted the Aboriginal Legal Rights Movement (ALRM) to inform them that the deceased had threatened to commit suicide. When the ALRM contacted Yalata, they were informed that the deceased had been placed in G Division for observation. However he was only in G Division for a few hours.

An ALRM representative visited the deceased soon afterwards and was told that although he had been angry as a result of problems with his girlfriend, he was okay now. The ALRM lawyer then asked the Manager of the Unit in which the deceased was housed to keep an eye on him. He was found the following day hanging in his cell, which was shared by another inmate who apparently slept through the incident.

The Corrective Services Minister said at the time that 'a review of Correctional Service Department procedures would take place to ensure they followed the requirements set out in the Royal Commission into Aboriginal Deaths in Custody.' 10

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Male 19, died 9 October 1995

Port Augusta Prison, SA

Self-inflicted mutilation

Coronial Inquiry Inquest not commenced

Social Justice Commissioner

Circumstances of death 11

The deceased was overheard by another Aboriginal prisoner in the early hours of the morning, who thought another prisoner was exercising when he heard soft moaning coming from the cell across from his. After the moaning became louder and more urgent the prisoner used his intercom to alert prison officers. The deceased used his intercom at the same moment to call for assistance.

When the officers arrived on the scene they unlocked the door and discovered the deceased lying on the floor surrounded by blood. He was still conscious and indicated to officers that he could not breathe. An ambulance was called but the deceased became unconscious and died despite attempts by prison and ambulance officers to resuscitate him. The (preliminary) conclusion was that death resulted from massive blood loss due to self-mutilation with a piece of broken glass that he had on his person.

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eg see Hippi v Nunn (Unreported, NSWSC, Herron J, 5 May 1995).

s25(2) Coroners Act 1975 (SA).

s19(2) Coroners Act 1985 (Vic).

4 The Commissioner for Police v Anderson (Unreported, NSWCA, Mahoney ACJ, Meahger and Beazley JJA, 40469/95).

5 Taken from press clippings on the Inquest to date and submission from ALRM.

The inquest was completed just before publication. The Social Justice Commissioner's comments have been amended slightly in light of the summing-up received.

7 Information taken from reports by Aboriginal Legal Rights Movement and SA Aboriginal Justice Advisory Committee.

Information provided by Aboriginal Legal Rights Movement

9 From information provided by the Aboriginal Legal Rights Movement, June 1996.

10 Koori Mail, 9 August 1995 at p3.

11 From information provided by the Aboriginal Legal Rights Movement June 1996.




report cover

A Report prepared by the

Office of the Aboriginal and Torres Strait Islander Social Justice Commissioner

for the

Aboriginal and Torres Strait Islander Commission